Robotic-assisted right ureterolysis

DISCHARGE DIAGNOSIS:  Proximal right ureteral stricture with retrocaval ureter.

PROCEDURES:  Robotic-assisted right ureterolysis.

BRIEF HISTORY:  This is an 80-year-old female with a history of dementia, hypothyroidism, and spinal stenosis who was initially admitted to the West Boca Medical Center in 08/2008 after a fall.  She had continued pain along the left side along with gross hematuria which prompted a CAT scan of her abdomen and pelvis.  The CAT scan of her abdomen and pelvis revealed a calculus in the right ureter with severe proximal right hydronephrosis, perinephric stranding, and periureteral inflammation.  She was observed overnight; however, pain did not subside, and she was taken to the operating room on 08/31/08.  A right ureteroscopy was performed which revealed a markedly tortuous right ureter with medial deviation, and it was unable to be stented from below.  She required a percutaneous nephrostomy tube for renal drainage on the right side that day.  Additionally, multiple times by interventional radiology was unsuccessful at bypassing the stricture in an antegrade fashion.  She was subsequently discharged and brought back to the hospital on 10/01/08 for a repeat attempt of right ureteroscopy.  We were unable to bypass the stenosis, tortuosity, and stricture of her right ureter in a retrograde fashion as well as an antegrade fashion down her nephrostomy tube tract.  The patient and family was consented in all the risks, benefits, alternatives were explained and they agreed to undergo a robotic-assisted laparoscopy right-sided ureteroureterostomy and ureterolysis for this obliterative stricture of her ureter.

PAST MEDICAL HISTORY:  Alzheimer’s dementia, hypothyroidism, and spinal stenosis.

ALLERGIES:  None.

MEDICINES:  Naprosyn, temazepam, Actonel, gabapentin, Namenda, Synthroid, Razadyne, and Aricept.

SOCIAL HISTORY:  Denies alcohol or drug use.  She currently lives with her daughter, although has been under rehab facility more recently.  Her daughter’s name is Alda Keene, and the phone number for her is 561-483-4348.

FAMILY HISTORY:  Denies history of renal disease, ureterolithiasis, and nephrolithiasis.

HOSPITAL COURSE:  On 10/29/08, the patient underwent a robotic-assisted laparoscopic ureterolysis with replacement of her nephrostomy tube.

SURGICAL FINDINGS:  A dilated ureter that course proximally and medially.  It appeared as if the ureter was completely encompassed by a dense inflammatory area of desmoplastic reaction with possible location in a retrocaval fashion.  At this point, we felt we would be putting the patient in excess harm to carry dissection behind the inferior vena cava and decided to leave her with an indwelling nephrostomy tube.  She tolerated the procedure well and there were no operative complications.  She recovered uneventfully.  At the time of discharge, she had a creatinine of 0.5 and a hemoglobin and hematocrit of 10.1/29.8.  There was no discharge medication.  She was sent back to her rehab facility with an indwelling right nephrostomy tube.  The patient’s family and I discussed that should they want further workup, MR urogram could be performed to further delineate the course of her ureter, and I did refer them for a second opinion should they want further surgical intervention to address her ureter.  I explained to them what our surgical findings were and that there was indeed a possibility of her having a retrocaval ureter which although may have not caused her issue for her lifetime.  A small stone may have lodged itself in the ureter causing a stricture and perinephric inflammation.  At this point, the family said they would like to avoid other interventions or satisfy with leaving the nephrostomy tube in place.  The patient was given instructions how to care for the nephrostomy tube and for the urine bag.  She was discharged to rehab in stable condition.  They will follow up with me as an outpatient to either arrange for serial nephrostomy tube changes or to discuss further evaluation and workup should they desire.